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r <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION tECEOVT <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503)588-7948 AUG 1 2021 <br /> http://www.co.marion.or.us/PWBuildingInspection MARION COUNTY <br /> BUILDING INSPECTION <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 444114 Cg2 c fn have authorized <br /> (Pr• erty Owner/Trim Name) <br /> 5©4 to act as my agent in performing the <br /> (Authorized Repres 1ntative/Print Name) <br /> activities necessary to obtain site evaluations, permits, and other onsite wastewater treatment program • <br /> services provided by the Department of Environmental Qnility or County Agent on the property <br /> described below in accordance with OAR chapter 340, division 071. <br /> • <br /> PROPERTY IDENTIFICATION: <br /> l�4 So/'II 7 G . 5i Ct. g R3 y� <br /> Property Situs or Street Address <br /> Described in the records of MARION County as:' <br /> Legal Description Tax Lot#(s) 9.3. -:2 <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: IA c' Ca v -e)'Signature G��/04.4v C �T � Date: 7---Z a-z1 <br /> Address: .S©/110/4 1q'1 Phone: 5-0 ?/U 30 <br /> City, State, Zip 6„-i-e S ,, 0 T T . 'T77 `f 6 Fax: <br /> E-mail Address 43c�o/2 ; -t-- 7 , cc..' <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: /26„ <br /> Company Name: h5-can <br /> Signature: Date: /Z.g/ t2,1-/ <br /> Address: IO tax- 6'1 // / 7-.1‘,m Phone: j c '--9 <br /> City, State, Zip /1li f( Gil . Or`. Fax: <br /> E-mail Address e..- f/- 6..E✓� <br /> DEQ License# 3 CCB# <br /> • <br /> G:WORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />